Hindawi Publishing Corporation

Journal of Ophthalmology
Volume 2015, Article ID 915853, 6 pages
http://dx.doi.org/10.1155/2015/915853

Clinical Study
Anterior and Posterior Corneal Astigmatism after Refractive
Lenticule Extraction for Myopic Astigmatism
Kazutaka Kamiya, Kimiya Shimizu, Mayumi Yamagishi,
Akihito Igarashi, and Hidenaga Kobashi
Department of Ophthalmology, University of Kitasato School of Medicine, Kanagawa 2520374, Japan
Correspondence should be addressed to Kazutaka Kamiya; kamiyak-tky@umin.ac.jp
Received 1 March 2015; Revised 25 April 2015; Accepted 27 April 2015
Academic Editor: Antonio Benito
Copyright 2015 Kazutaka Kamiya et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Purpose. To assess the amount and the axis orientation of anterior and posterior corneal astigmatism after refractive lenticule
extraction (ReLEx) for myopic astigmatism. Methods. We retrospectively examined 53 eyes of 53 consecutive patients (mean age
standard deviation, 33.2 6.5 years) undergoing ReLEx to correct myopic astigmatism (manifest cylinder = 0.5 diopters (D)).
Power vector analysis was performed with anterior and posterior corneal astigmatism measured with a rotating Scheimpflug
system (Pentacam HR, Oculus) and refractive astigmatism preoperatively and 3 months postoperatively. Results. Anterior corneal
astigmatism was significantly decreased, measuring 1.42 0.73 diopters (D) preoperatively and 1.11 0.53 D postoperatively
( < 0.001, Wilcoxon signed-rank test). Posterior corneal astigmatism showed no significant change, falling from 0.44 0.12
D preoperatively to 0.42 0.13 D postoperatively ( = 0.18). Refractive astigmatism decreased significantly, from 0.92 0.51 D
preoperatively to 0.27 0.44 D postoperatively ( < 0.001). The anterior surface showed with-the-rule astigmatism in 51 eyes
(96%) preoperatively and 48 eyes (91%) postoperatively. By contrast, the posterior surface showed against-the-rule astigmatism in
all eyes preoperatively and postoperatively. Conclusions. The surgical effects were largely attributed to the astigmatic correction of
the anterior corneal surface. Posterior corneal astigmatism remained unchanged even after ReLEx for myopic astigmatism.

1. Introduction
Accurate astigmatic correction is crucial when attempts are
made to achieve better visual performance through refractive
surgery. The femtosecond laser is one of the most significant
revolutionary inventions in recent medical technology and,
in ophthalmology, has been used mainly for the creation
of corneal flaps for laser in situ keratomileusis (LASIK). A
recent breakthrough in this technology has resulted in a novel
refractive procedure called refractive lenticule extraction
(ReLEx), which requires neither a microkeratome nor an
excimer laser but uses only the femtosecond laser system as an
all-in-one device for flap and lenticule processing. The ReLEx
technique, which can be used for femtosecond lenticule
extraction (FLEx) [15] by lifting the flap and by small
incision lenticule extraction (SMILE) [3, 614] without lifting

the flap, has been proposed as an alternative to conventional

LASIK for the correction of refractive errors.
Recently, the development of new technologies, such as
slit-scanning devices, Scheimpflug devices, and optical coherence tomography, has made the quantitative measurement of
the posterior corneal curvature in a clinical setting possible.
Since corneal refractive surgery inevitably induces damage
in corneal biomechanics [15], it is possible that even the
postoperative shape of the posterior corneal surface may
change with time. However, to our knowledge, posterior
corneal astigmatism after corneal astigmatic surgery has
not fully elucidated. The current study was designed to
retrospectively assess the amount and the axis orientation
of corneal astigmatism of the anterior and posterior corneal
surfaces as well as refractive astigmatism after ReLEx for
myopic astigmatism.

2. Patients and Methods

Fifty-three eyes of 53 patients (23 men and 30 women) who
underwent ReLEx (FLEx: 23 eyes and SMILE: 30 eyes) for
the correction of myopic astigmatism (manifest cylinder 0.5
diopters (D)) with good quality scans of corneal tomography
measured with a Scheimpflug anterior segment photography
system (Pentacam HR, Oculus, Wetzlar, Germany) were
included in this observational study. The patients were
recruited in a continuous cohort. Only one eye per subject
was selected randomly for statistical analysis. The subjects
were in part comprised of those in the preceding report on
visual and refractive outcomes after FLEx and SMILE [7].
Otherwise, we performed FLEx or SMILE, according to the
time of surgery (FLEx: up to and including November 2011;
SMILE: December 2011 onwards), regardless of the amount
of preoperative manifest equivalent refraction or cylindrical
refraction. The sample size in this study offered 94.6% statistical power at the 5% level in order to detect a 0.25-diopter (D)
difference in manifest cylinder, when the standard deviation
(SD) of the mean difference was 0.50 D. The inclusion criteria
for this study were as follows: corrected distance visual acuity
(CDVA) of 20/20 or more, dissatisfaction with correction
using spectacles or contact lenses for nonoptical reasons,
manifest spherical equivalent of 1.00 to 9.00 D, manifest
cylinder of 0.50 D or more, sufficient corneal thickness (estimated total postoperative corneal thickness >400 m and
estimated residual thickness of the stromal bed >250 m),
absence of a history of ocular surgery, severe dry eye,
progressive corneal degeneration, cataract, or uveitis. Eyes
with keratoconus were excluded from the study by using the
keratoconus screening test of Placido disk videokeratography
(TMS-2, Tomey, Nagoya, Japan). Written informed consent
for the surgery was obtained from all patients after explanation of the nature and possible consequences of the study. This
retrospective review of data was approved by the Institutional
Review Board at Kitasato University and followed the tenets
of the Declaration of Helsinki. The authors Institutional
Review Board waived the requirement for informed consent
for this retrospective study.
2.1. Refractive Lenticule Extraction Surgical Procedures. Both
FLEx and SMILE were performed using the VisuMax femtosecond laser system (Carl Zeiss Meditec AG) with a
500 kHz repetition rate [5, 7]. The laser was visually centered
on the pupil. A small (S) curved interface cone was used in
all cases. The main refractive and nonrefractive femtosecond incisions were performed in the following automated
sequence: the posterior surface of the lenticule (spiral in
pattern) and the anterior surface of the lenticule (spiral out
pattern), followed by a side cut of flap. The femtosecond laser
parameters were as follows: 120 m flap thickness, 7.5 mm flap
diameter, 6.5 mm lenticule diameter, 140 nJ power for lenticule and flap, and a 310 side cut (superior hinge) with side
cut angles of 90 for FLEx and 120 m flap thickness, 7.5 mm
diameter of anterior lenticule surface, 6.5 mm diameter of
posterior lenticule surface, 140 nJ power for lenticule and flap,
and a 50 side cut for access to the lenticule with angles of 90
for SMILE. In all eyes, the preoperative manifest refraction

Journal of Ophthalmology
was selected as the target myopic correction. After the suction
was released, the patient was moved towards the observation
position under the VisuMax integrated surgical microscope.
For FLEx, after completion of the laser sequence, a Siebel
spatula was inserted under the flap near the hinge and the
flap was lifted, and the refractive lenticule was then grasped
with forceps and extracted. The flap was then repositioned.
For SMILE, a thin spatula is inserted through the side cut
over the roof of the refractive lenticule dissecting this plane
followed by the bottom of the lenticule. The lenticule is subsequently grasped with modified serrated McPherson forceps
(Geuder GmbH, Heidelberg, Germany) and removed. After
the removal of the lenticule, the intrastromal space is flushed
using a standard LASIK irrigating cannula. After surgery,
steroidal (0.1% betamethasone, Rinderon, Shionogi, Osaka,
Japan) and antibiotic (0.5% levofloxacin, Cravit, Santen,
Osaka, Japan) medications were topically administered 4
times daily for 2 weeks, and then the frequency was steadily
reduced.
2.2. Assessment of Corneal Astigmatism. The amount and the
axis orientation of anterior and posterior corneal astigmatism
within the central 3.0 mm were automatically measured with
the Scheimpflug system (Pentacam HR). This device collects
25,000 true elevation data points, which are processed to generate a 3-dimensional representation of the anterior eye. We
took at least three measurements and used the average value
for statistical analysis. We classified astigmatism as with-therule (WTR) when the steep meridian on the corneal surface
was between 60 and 120 degrees and as against-the-rule
(ATR) when the steep meridian on the corneal surface was
between 0 and 30 degrees or between 150 and 180 degrees.
Since the dioptric power of the posterior corneal surface was
negative, we classified posterior corneal astigmatism as WTR
when the steep meridian on the corneal surface was between
0 and 30 degrees or between 150 and 180 degrees and as ATR
when the steep meridian on the corneal surface was between
60 and 120 degrees. We classified the remaining astigmatism
as oblique astigmatism, as described previously [16].
2.3. Power Vector Analysis. Spherocylindrical refraction results were converted to vectors expressed by 3 dioptric
powers: , 0 , and 45 , where is equal to the spherical
equivalent of the given refractive error and 0 and 45 are the 2
Jackson cross cylinder equivalents to the conventional cylinder. Manifest refractions were recorded in conventional script
notation (sphere, cylinder, and axis) and then converted
to the power vector coordinates described by Thibos and
Horner [17] and to overall blurring strength by the following
formulas:

,
2

0 = ( ) cos (2) ,
2

45 = ( ) sin (2) ,
2
=+

= (2 + 0 2 + 45 2 )

(1)
1/2

Journal of Ophthalmology

3
Table 1: Preoperative and postoperative demographics of the study population.

Age (years)
Gender
LogMAR UDVA
LogMAR CDVA
Manifest spherical equivalent (D)

value

Preoperative
Postoperative
33.2 6.5 years (95% CI, 20.4 to 46.0 years)
Male : female = 23 : 30
1.15 0.25 (95% CI, 0.66 to 1.63)
0.14 0.12 (95% CI, 0.38 to 0.09)
0.21 0.08 (95% CI, 0.36 to 0.06)
0.20 0.08 (95% CI, 0.36 to 0.04)
4.72 1.57 D (95% CI, 1.64 to 7.80 D)
0.06 0.32 D (95% CI, 0.06 to 2.15 D)

<0.001
0.501
<0.001

CI: confidence interval, LogMAR: logarithm of the minimal angle of resolution, UDVA: uncorrected distance visual acuity, CDVA: corrected distance visual
acuity, and D: diopter.

2.4. Statistical Analysis. All statistical analyses were performed using Ekuseru-Toukei 2010 (Social Survey Research
Information Co. Ltd., Tokyo, Japan). Fishers exact test was
used to compare the preoperative and postoperative axis
orientation of astigmatism. Otherwise, since normal distribution of the data was not confirmed with the KolmogorovSmirnov test, the Wilcoxon signed-rank test was used to
compare the preoperative and postoperative data. The results
are expressed as mean SD, and a value of < 0.05 was
considered statistically significant.

3. Results
3.1. Study Population. Preoperative and postoperative demographics of the study population are listed in Table 1. All
surgeries were uneventful and no definite intraoperative
complications were observed. A transient interface haze
developed in 3 eyes (6%) 1 week postoperatively but gradually
resolved thereafter without surgical intervention. No epithelial ingrowth, diffuse lamellar keratitis, iatrogenic ectasia, or
any other vision-threatening complications were seen at any
time during the observation period. No eyes were lost during
the 3-month follow-up in this series.
3.2. Amount and Axis Orientation of Corneal and Refractive
Astigmatism. Preoperative and postoperative anterior and
posterior corneal astigmatism and refractive astigmatism
are summarized in Table 2. Anterior corneal astigmatism
and refractive astigmatism were significantly decreased after
surgery ( < 0.001, Wilcoxon signed-rank test), whereas posterior corneal astigmatism was not significantly decreased
after surgery ( = 0.175). The anterior corneal surface
showed with-the-rule astigmatism in 51 eyes (96%) preoperatively and 48 eyes (91%) postoperatively. On the other
hand, the posterior corneal surface showed against-the-rule
astigmatism in all eyes preoperatively and postoperatively.
3.3. Power Vector Analysis. The changes in the astigmatic
power vector between preoperative and postoperative values

4
3
2
J45 (diopters)

where is the spherical lens equal to the spherical equivalent

of the given refractive error; is the sphere; is the cylinder;
0 is the Jackson cross cylinder, axes at 180 degrees and 90
degrees; is the axis; 45 is the Jackson cross cylinder, axes
at 45 degrees and 135 degrees; and is the overall blurring
strength of the spherocylindrical refractive error.

1
0
1
2
3
4

J0 (diopters)

Before surgery
After surgery

Figure 1: Power vector analysis of anterior corneal astigmatism

before and after refractive lenticule extraction (ReLEx), plotted as
an astigmatic vector for each eye, referenced to the spectacle plane.

of anterior and posterior corneal astigmatism and refractive

astigmatism for all cases are presented in Figures 13. The
preoperative and postoperative distribution of anterior and
posterior corneal astigmatism, refractive astigmatism, and
refraction after vector conversion is shown in Table 2. For
anterior corneal astigmatism, the dispersed cluster of points
before surgery tended to collapse around the origin after
surgery, indicating a reduction in vector astigmatic change.
For 0 , 57% of eyes were within 0.5 D and 92% were within
1.0 D. For 45 , 100% of eyes were within 0.5 D after surgery.
For posterior corneal astigmatism, the dispersed cluster of
points before surgery tended to remain unchanged after
surgery, indicating no reduction in vector astigmatic change.
For 0 and 45 , 100% of eyes were within 0.5 D after surgery.
For refractive astigmatism, the dispersed cluster of points
before surgery tended to collapse around the origin after
surgery. For 0 , 96% of eyes were within 0.5 D and 100%
were within 1.0 D. For 45 , 96% of eyes were within 0.5 D
and 100% were within 1.0 D after surgery. The changes
in anterior and posterior corneal astigmatism, refractive
astigmatism, and refraction after vectorial conversion in

Journal of Ophthalmology

Table 2: Preoperative and postoperative anterior and posterior corneal astigmatism, refractive astigmatism, and refraction after vectorial
conversion in eyes undergoing refractive lenticule extraction.
Preoperative
Amount (D)
With-the-rule
astigmatism
Against-the-rule
astigmatism
Oblique astigmatism
0
45
Amount (D)
Against-the-rule
astigmatism
0
45
Amount (D)
With-the-rule
astigmatism
Against-the-rule
astigmatism
Oblique astigmatism

0
45

value

Postoperative

Anterior corneal astigmatism

1.42 0.73 D (95% CI, 0.02 to 2.86 D)
1.11 0.53 D (95% CI, 0.00 to 2.00 D)
51 eyes (96%)

48 eyes (91%)

0 eyes (0%)

1 eye (2%)

2 eyes (4%)
0.67 0.38 D (95% CI, 0.08 to 1.41 D)
0.02 0.22 D (95% CI, 0.45 to 0.41 D)

4 eyes (8%)
0.48 0.31 D (95% CI, 0.13 to 1.08 D)
0.00 0.23 D (95% CI, 0.46 to 0.46 D)

<0.001
0.437

<0.001
0.460

Posterior corneal astigmatism

0.44 0.12 D (95% CI, 0.20 to 0.69 D)
0.42 0.13 D (95% CI, 0.16 to 0.68 D)

0.175

53 eyes (100%)

53 eyes (100%)

1.000

0.21 0.06 D (95% CI, 0.09 to 0.33 D)

0.01 0.06 D (95% CI, 0.13 to 0.11 D)

0.20 0.07 D (95% CI, 0.07 to 0.33 D)

0.00 0.06 D (95% CI, 0.12 to 0.11 D)

<0.001
0.489

Refractive astigmatism
0.92 0.51 D (95% CI, 0.07 to 1.92 D)
0.27 0.44 D (95% CI, 0.59 to 1.13 D)

<0.001

43 eyes (81%)

48 eyes (91%)

0.135

6 (11%)

5 eyes (9%)

4 eyes (8%)
4.72 1.57 D (95% CI, 7.80 to 1.60 D)
0.32 0.38 D (95% CI, 0.42 to 1.07 D)
0.03 0.18 D (95% CI, 0.37 to 0.32 D)
4.75 1.56 D (95% CI, 1.69 to 7.82 D)

0 eyes (0%)
0.04 0.32 D (95% CI, 0.67 to 0.60 D)
0.04 0.21 D (95% CI, 0.38 to 0.46 D)
0.01 0.14 D (95% CI, 0.29 to 0.27 D)
0.26 0.32 D (95% CI, 0.37 to 0.89 D)

<0.001
<0.001
0.489
<0.001

CI: confidence interval, D: diopter, : spherical equivalent refraction, 0 : Jackson cross cylinder, axes at 0 and 90 degrees, 45 : Jackson cross cylinder, axes at
45 and 135 degrees, and : blur strength.

the FLEx and SMILE subgroups are also shown in Table 3.

We found no significant differences in the changes in any
parameters between the two groups ( > 0.05).

4
3

4. Discussion
In the present study, our results demonstrated that ReLEx
provides good astigmatic outcomes for the correction of
myopic astigmatism. This effect was largely attributed to the
astigmatic correction of the anterior corneal surface, whereas
the posterior corneal surface did not significantly contribute
to the astigmatic correction. To our knowledge, this is the
first study to assess the amount and the axis orientation
of anterior and posterior corneal astigmatism after corneal
astigmatic surgery. As shown in the results, preoperatively,
the anterior corneal surface exerts approximately 3.2 times
the amount of astigmatism caused by the posterior corneal
surface preoperatively. Contrary to our expectations, the
anterior corneal surface still exerted approximately 2.6 times
amount of astigmatism that the posterior corneal surface
did 3 months postoperatively, although the postoperative

J45 (diopters)

2
1
0
1
2
3
4

J0 (diopters)

Before surgery
After surgery

Figure 2: Power vector analysis of posterior corneal astigmatism

before and after refractive lenticule extraction (ReLEx), plotted as
an astigmatic vector for each eye, referenced to the spectacle plane.

Journal of Ophthalmology

Table 3: Changes in anterior and posterior corneal astigmatism, refractive astigmatism, and refraction after vectorial conversion in eyes
undergoing femtosecond lenticule extraction (FLEx) and small incision lenticule extraction (SMILE).
FLEx group

SMILE group
Anterior corneal astigmatism
0.33 0.61 (95% CI, 0.85 to 1.52)
0.30 0.54 (95% CI, 0.76 to 1.35)
0.22 0.30 (95% CI, 0.37 to 0.81)
0.17 0.28 (95% CI, 0.39 to 0.72)
0.01 0.27 (95% CI, 0.53 to 0.55)
0.05 0.24 (95% CI, 0.52 to 0.43)
Posterior corneal astigmatism
0.03 0.10 (95% CI, 0.17 to 0.23)
0.01 0.08 (95% CI, 0.15 to 0.17)
0.02 0.05 (95% CI, 0.08 to 0.11)
0.00 0.04 (95% CI, 0.07 to 0.08)
0.00 0.05 (95% CI, 0.10 to 0.11)
0.01 0.04 (95% CI, 0.08 to 0.06)
Refractive astigmatism
0.49 0.58 (95% CI, 1.62 to 0.64)
0.78 0.44 (95% CI, 1.64 to 0.09)
4.68 1.35 (95% CI, 7.32 to 2.04)
4.69 1.77 (95% CI, 8.16 to 1.21)
0.31 0.29 (95% CI, 0.26 to 0.88)
0.26 0.34 (95% CI, 0.40 to 0.92)
0.01 0.30 (95% CI, 0.59 to 0.58)
0.02 0.18 (95% CI, 0.38 to 0.33)
4.45 1.36 (95% CI, 1.79 to 7.11)
4.53 1.79 (95% CI, 1.03 to 8.04)

Amount (D)
0
45
Amount (D)
0
45
Amount (D)

0
45

value
0.943
0.435
0.374
0.428
0.121
0.108
0.082
0.788
0.788
0.733
0.753

FLEx: femtosecond lenticule extraction, SMILE: small incision lenticule extraction, CI: confidence interval, D: diopter, : spherical equivalent refraction, 0 :
Jackson cross cylinder, axes at 0 and 90 degrees, 45 : Jackson cross cylinder, axes at 45 and 135 degrees, and : blur strength.

4
3

J45 (diopters)

2
1
0
1
2
3
4

J0 (diopters)

Before surgery
After surgery

Figure 3: Power vector analysis of refractive astigmatism before and

after refractive lenticule extraction (ReLEx), plotted as an astigmatic
vector for each eye, referenced to the spectacle plane.

refractive astigmatism was decreased to approximately onethird of the preoperative refractive astigmatism. Most eyes
showed WTR astigmatism of the anterior corneal surface
not only preoperatively but also postoperatively, presumably
because the patients in the study population were relatively
young and because the surgical nomograms for ReLEx aimed
at slight undercorrection in order to prevent overcorrection
of the astigmatism. On the other hand, all eyes showed ATR
astigmatism of the posterior corneal surface preoperatively
and postoperatively, suggesting that the axis orientation of
the posterior corneal surface remained unchanged even after
corneal astigmatic surgery.
The residual cylindrical error observed after ReLEx may
be attributed to the absence of use of iris registration software

to compensate for ocular cyclotorsion or of specific surgical

nomograms for ReLEx. During LASIK, cyclotorsional misalignment between the ablation pattern and the eye can result
in residual undercorrection of astigmatism postoperatively,
and the amount of residual cylindrical error per diopter of
preexisting cylinder has been shown to be associated with the
amount of cyclotorsion [18]. It has been also demonstrated
that iris registration with eye tracking gave better astigmatic
outcomes than when no iris registration was performed in
a clinical setting [19]. Further improvements that will compensate for ocular cyclotorsion during the ReLEx procedure
are necessary to provide even better improved astigmatic
outcomes, although the mean residual error of astigmatism
after ReLEx was very small (approximately 0.25 D). In the
subgroup analysis, there were no significant differences in
the changes in any astigmatic parameters between the FLEx
and SMILE groups, indicating that the astigmatic correction
of FLEx is essentially equivalent to that of SMILE for the
correction of anterior and posterior corneal astigmatism and
refractive astigmatism.
This study is burdened with at least two limitations to this
study. One is that we determined the postoperative astigmatism 3 months postoperatively, when the corneal shape was
considered to have stabilized, taking into account the woundhealing responses of the cornea. A longer follow-up is still
necessary to confirm the correctness of the astigmatic results.
Another limitation is that we did not assess the repeatability
of the measurements, especially those of posterior corneal
astigmatism. However, this Scheimpflug system has been
shown to provide posterior corneal curvature measurements
with excellent repeatability even after LASIK [20].
In conclusion, our results demonstrated that ReLEx
performed well in the correction of myopic astigmatism. The
astigmatic correction was largely attributed to the astigmatic
correction of the anterior corneal surface as compared
with that of the posterior corneal surface. Posterior corneal
astigmatism remained unchanged even after ReLEx for the
correction of myopic astigmatism.

Journal of Ophthalmology

Ethical Approval
The study was approved by the Institutional Review Board at
Kitasato University School of Medicine.

[9]

Disclosure
The funders had no role in study design, data collection and
analysis, decision to publish, or preparation of the paper.

Conflict of Interests
The authors report no conflict of interests. The authors alone
are responsible for the content and writing of the paper.
The authors have no competing interests in the materials
presented herein.

[10]

[11]

[12]

Acknowledgment
This work was supported in part by Grant-in-Aid for Scientific Research from the Ministry of Education, Culture,
Sports, Science and Technology of Japan (15K10846).

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